Saturday, April 5, 2014

‘Well, what diets have you tried so far?’ asked the GP, flicking through the patient’s notes. I was an innocent trainee doctor on my general practice placement at the time and watched the interaction carefully, sensing a row was about to ensue. ‘Look, I don’t want to go on a diet, I want you to prescribe me these,’ snapped the patient, bringing out a neatly folded page she had torn out of a magazine. The GP, rolling his eyes at me, took the paper but didn’t read it. I suspected he’d read it before. This was yet another example of what’s becoming a very British epidemic: obesity being self-diagnosed as disease.

The doctor attempted to explain that tablets really aren’t suitable in her case. As well as having some potentially nasty side effects, they’re expensive to prescribe, and don’t offer a long-term solution. This was clearly not what the woman wanted to hear. ‘Fine then, don’t help me, see if I care. I’ll get my sister to get them off her GP — he gives her whatever she wants’; and she stormed out. It struck me as bizarre that while some people using the NHS are dangerously malnourished, other people are desperate to take tablets to ensure that their food passes through their body unabsorbed, while the taxpayer foots the bill.

It happens all the time. The patients who are not interested in changing their diet in any way, demanding to have their cake, eat it and then pop a pill so that the calories never touch their waistline. And as a result, Britain now combines austerity with obesity. The majority of us are now overweight or obese — a third of children are considered too heavy. It costs an extra £5 billion a year, and 300 hospital admissions a day are directly due to obesity. To pick up the newspapers is to witness a country adjusting itself to losing a national battle of the bulge.

Take the East Midlands Ambulance Service. It emerged this week that it has been picking up so many fat patients — weighing in excess of the 28-stone maximum — that it needs a new fleet. It has, hitherto, been struggling along with just one ambulance for fatties (a ‘bariatric’ vehicle), but now thinks all 272 of its ambulances need to be upgraded with double-wide stretchers for patients who (it says) can weigh in at 55 stone. The plan will cost £27 million.

Once the obese patient is in hospital, a whole new set of equipment is required: reinforced operating tables, sturdier trollies, longer needles and even wider MRI scanners. There is a great demand for bariatric surgeons. One of them, Sally Norton, recently wrote in the Royal College of Surgeons’ house journal that without special equipment for the obese, there may be ‘enquiries into the potential use of veterinary or zoological scanners, with resultant loss of dignity for the patient’. There is a cost to all this: in the kit, and in operations like gastric bypass operations, which have increased sevenfold over the last seven years.

Moving obese patients out of their house can be too difficult for the NHS. Recently the fire service had to demolish two walls of a house in south Wales so that a 63-stone teenager could be taken to hospital. This required more than 40 emergency service workers at an estimated cost of £100,000. Over the past five years, fire services have been called to more than 2,700 incidents to assist ‘severely obese’ people, including some who had got stuck in the bath. Rescuing fatties is now a routine operation, with its own entry in the Fire Brigade incident reporting system (filed under ‘bariatric persons’).

So what to do? The government spends money asking us to eat ‘five a day’ fruit and veg, but it seems to have no effect. Nottingham, the fattest region in Britain, recently decided to spend £500,000 on replacing pavements in areas with particularly fat pedestrians, to try and encourage people to walk more. Our landscape is being, quite literally, reshaped in order to accommodate the obese. In the past few years, we have moved from being outraged about the epidemic to just planning around it. Like a middle-aged man deciding to eat what he wants and let himself go, Britain is pulling on a pair of tracksuit bottoms and heading to the fridge.

It need not be this way. For too long, my fellow doctors have pussyfooted around their obese patients, too scared to confront the, er, elephant in the room. They don’t want to cause offence. Unbelievably, draft guidelines announced last year by the National Institute of Clinical Excellence and Health (Nice) suggested that doctors should even avoid the use of the term ‘obese’ for fear that larger patients might be upset. Instead, Nice recommended advising corpulent patients that they should seek a ‘healthier weight’.

But nice euphemisms mean that people don’t confront reality. I’m not going to stop diagnosing cancer just because people don’t like hearing the dreaded word. So why should it be different when informing people that they are obese? Sometimes morbidly so. What Nice is delicately skirting round is what many doctors, nurses and dieticians will confirm: people don’t like being told that they are overweight, even if it’s objectively clearly the case. And by pretending that this is a disease, the doctors are making it even worse.

There’s something comforting about blaming obesity on genes. It enables people to relinquish responsibility for their weight, which can be seen as outside their control. It’s nothing new, either. Years ago, fat people blamed their ‘glands’. When I started medical school, I patiently waited for us to be taught about these magical ‘glands’ that made people fat. I’m still waiting. Even when people have problems with an underactive thyroid, which can slow the metabolism and result in weight gain, this can be treated with thyroid replacement tablets and the metabolism returns to normal. As a rule, however, fat people have one thing in common: they eat more than they need to.

Certainly some people metabolise food at a different rate to others, meaning they are more likely to lay down fat stores than other people. But this is a reason to eat less, not to become fat. You cannot get away from the basic biology of the human body — fat is simply stored excess energy, and weight gain is only possible when the total amount of energy consumed exceeds the total amount of energy expended. Even those who have a genetic predisposition to become fat are not slaves to their DNA.

An in-depth study published last year, which looked at the genes of more than 20,000 people and was conducted at the Medical Research Council’s epidemiology unit in Cambridge, found some people are predisposed to be overweight. But an active lifestyle and reducing food intake can counteract that. Simple. While some will be annoyed by this research, I find it empowering. The idea that our genes control us is profoundly depressing. After all, there is more to being human than a few strands of DNA.

The rate of people considered clinically obese has risen from around 1 to 2 per cent of the population in the 1960s to over 25 per cent now. Why? A simple answer would be lifestyle, but it’s actually a little more complicated. A fascinating survey conducted by the Department of Health compared data collected from 1967 and 2010. It showed that, while people back then were slimmer, they ate fattier foods and had access to far fewer gyms. We eat better now, we work out more. But we live relatively sedentary lives. Only three out of ten households had a car then, compared to seven out of ten now. While 75 per cent of people walked for at least half an hour a day in the 1960s, this is only about 40 per cent now.

What really stands out, more than the lifestyle differences, is the sharp contrast in the attitudes towards obesity between the two different eras. The 1967 survey found that nine out of ten people had attempted to lose weight in the past year, compared with barely half of adults questioned in 2010. Perhaps most tellingly though, 40 years ago only 7 per cent of those people who considered themselves overweight had failed to do anything about it, compared with nearly half now.

It would be easy to blame Britain’s fatness on lifestyle changes, but the worst of it is attitude. People just aren’t bothering to lose weight any more. Perhaps obesity is viewed as more normal. But this is also down to the attitude that we doctors increasingly encounter in our consulting rooms: the reluctance of patients to accept that ailments can be blamed on their behaviour, for which they are reluctant to take responsibility.

Patients blame obesity on the government, cunning food manufacturers, their parents and their genes. They demand fat-loss pills on the NHS and stomach-stapling surgery as a right. In a world where health care is becoming consumerised, patients see themselves as customers. There’s not much demand for hard truths.

America has severe obesity problems, and seems resigned to them. But Britain has a National Health Service, and therefore a far higher capacity to change. It ought to be easy. Doctors should be required to tell patients a blunt truth: if you’re fat, eat less, exercise more, or both. And if you keep guzzling the tasty treats, you will die earlier. It’s not a disease, it’s a mindset — and that means it can be changed. We doctors need to be a little less understanding, a little more judgmental, and realise that our oath — ‘do no harm’ — must come before our desire to save the feelings of our patients. The truth can be the hardest drug to administer. But holding our tongues, prescribing the fat pills and bankrupting the NHS in the process is the worst solution of all.